LIFE IN THE END ZONE: A discussion of topical issues for anyone concerned with the final phase of life by Muriel R. Gillick, MD

February 25, 2017

Stiff Upper Lip?

The British, I’ve argued previously, are ahead of us in health care for
older people. They have more robust geriatric and palliative care programs than
we do. They screen for frailty in older people and have a strategy for
addressing the needs of those found to be frail. They devote a larger fraction
of their resources to primary care (as opposed to specialty care) than we do,
which benefits the aging. And data from the Commonwealth Fund consistently show
that even though the UK spends a smaller percentage of its GDP and much less
per capita on health care than does the US, health outcomes are typically at
least as good and often better. In the fund’s most recent report, for example,
the US does well in cancer care but has higher mortality from ischemic heart
disease and higher rates of diabetic complications than the UK: death rate from
IHD was 128/100,000 in the US compared to 98/100,000 in the UK and amputations
in diabetics occurred in 17.1/100,000 in the US compared to 5.1/1000 in the UK.
So the report published this month called “Health and Care of Older People in England 2017” was of great interest.

The basic demographic reality in England is the same as in the
United States: the population is aging and the oldest old, those over age 85,
are the fastest growing subset of the older cohort. And the economic reality in
England may well foreshadow its American counterpart: over the last several
years, the UK has been in the grip of belt-tightening fever, as government
spending on both medical care and social services has been cut or its rate of
growth slowed. The net effect is that gains in life expectancy leveled off by
2011, but more alarming, disability-free life expectancy at age 65 has been
falling since 2011. Between 2005 and 2011, older women gained a full half year
of good health and men gained 0.3 years. Since then, most of those gains have
been lost.

Another result is that over a single year, there has been an 18
percent increase in the number of people who do not get the basic help with their
activities of daily life that they need.

The authors of the study conclude that the “massive reduction in
publicly funded social care has had a severe impact on older people,
families, and carers.” Five years of cutbacks have led to a 26 percent increase
in the number of older people with unmet needs for care and support. And this
is in a country where there is a lower rate of obesity and fewer chronic
diseases per person than in the US.

What’s particularly interesting is that the UK has for years devoted
far more resources to social support for older people than has the US. The
possibility that the mediocre or downright poor health outcomes for Americans (despite
a per capital medical expenditure of more than double that of other developed
countries) is attributable to lack of spending on social services was first raised by Elizabeth Bradley at Yale. She found intriguing evidence that the
added dollars lavished on physician care, hospital care, and diagnostic tests,
among other outlays, were not nearly as valuable as the money spent on
supporting caregivers and home care. And a recent RAND study, “Are Better Health Outcomes Related to Social Expenditures?” which was commissioned to challenge
Bradley’s findings, instead confirmed them. Moreover, this analysis concluded that
public social expenditures (as opposed to the private ones that are favored in
the US) have a particularly strong relationship with health outcomes. It also
found that certain social expenditures such as spending on old age care,
translate into better health outcomes throughout the life cycle (ie support
middle aged caregivers and they and their children are healthier). Finally, the
study concluded that the role of social expenditures is magnified in countries
with a high degree of income inequality—such as the US.

The US is on the brink of rolling back government programs. Presumably, what little support is currently provided to older people and their families is a candidate for the chopping block. The British experience shows us what sort of improvements in health and well-being are achievable for older people--and also what happens when social programs are cut. Caveat emptor!